Systemic Immunomodulators Medication New Hampshire Medicaid Prior Authorization Request Form Fax to Magellan if medication is to be dispensed from a pharmacy Magellan: Fax: 1‐888‐603‐7696 Phone: 1‐866‐675‐7755 Fax to KePRO if medication is dispensed/administered by a physician in the office or outpatient setting